1. health and fitness
2. disease
3. ibs and crohn's disease

Journal of Pediatric Gastroenterology and Nutrition
40:249–261 Ó March 2005 Lippincott Williams & Wilkins, Philadelphia
Technical Report
Chronic Abdominal Pain In Children: A Technical Report
of the American Academy of Pediatrics and the
North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition
AAP Subcommittee and NASPGHAN Committee on Chronic Abdominal Pain
ABSTRACT
Chronic abdominal pain, defined as long-lasting intermittent or
constant abdominal pain, is a common pediatric problem
encountered by primary care physicians, medical subspecialists
and surgical specialists. Chronic abdominal pain in children is
usually functional—that is, without objective evidence of an
underlying organic disorder. The Subcommittee on Chronic
Abdominal Pain of the American Academy of Pediatrics and
the North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition has prepared this report based on
a comprehensive, systematic review and rating of the medical
literature. This report accompanies a clinical report based on
the literature review and expert opinion.
The subcommittee examined the diagnostic and therapeutic
value of a medical and psychologic history, diagnostic tests, and
pharmacological and behavioral therapy. The presence of alarm
symptoms or signs (such as weight loss, gastrointestinal
bleeding, persistent fever, chronic severe diarrhea and significant vomiting) is associated with a higher prevalence of organic
disease. There was insufficient evidence to state that the nature of
the abdominal pain or the presence of associated symptoms (such
as anorexia, nausea, headache and joint pain) can discriminate
between functional and organic disorders. Although children
with chronic abdominal pain and their parents are more often
anxious or depressed, the presence of anxiety, depression, behavior problems or recent negative life events does not distinguish
between functional and organic abdominal pain. Most children
who are brought to the primary care physician’s office for
chronic abdominal pain are unlikely to require diagnostic testing.
Pediatric studies of therapeutic interventions were examined
and found to be limited or inconclusive. JPGN 40:249–261, 2005.
Key Words: Abdominal pain—Functional bowel disorders—
Irritable bowel syndrome—Dyspepsia—Stress—Anxiety—
Depression. Ó 2005 Lippincott Williams & Wilkins
INTRODUCTION
known but is likely to be substantial, considering that
expenses associated with irritable bowel syndrome (IBS)
in adults have been estimated to be $8 billion to $30
billion per year (4–6). The long-term outcome of this
condition has not been determined, but preliminary data
indicate that young adults with a history of recurrent
abdominal pain that began in childhood who are treated
by a subspecialist are significantly more likely than their
peers without recurrent abdominal pain to have lifelong
psychiatric problems and migraine headaches (7). Despite the high prevalence and effects of this condition,
no evidence-based guidelines for its evaluation and
treatment exist.
With this background in mind, the American Academy
of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition established a subcommittee charged with developing evidencebased guidelines for the evaluation and treatment of
chronic abdominal pain in children. A major problem in
The exact prevalence of chronic abdominal pain in
children is not known. It appears to account for 2% to 4%
all of pediatric office visits (1). One study suggested that
13% of middle school students and 17% of high school
students experience weekly abdominal pain (2). In the
latter study, it was also noted that approximately 8% of
all students had seen a physician for evaluation of abdominal pain in the previous year. Quality of life in adult
patients with chronic abdominal pain is substantially
poorer than that of the general population (3). The economic cost related to this condition in children is not
This Technical Report is being published simultaneously in
Pediatrics and Journal of Pediatric Gastroenterology and Nutrition.
All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised or retired at or before that time.
249
250
NASPGHAN
reviewing the literature arose in defining criteria for
recurrent or chronic abdominal pain. For many years, the
term ‘‘recurrent abdominal pain’’ has been used to describe all cases without an organic etiology. It was first
introduced in the pediatric literature by Apley and Naish
(8) in the late 1950s during an era when some organic
gastrointestinal disorders had not been fully appreciated.
Children were considered to have recurrent abdominal
pain if they had experienced at least three bouts of pain
severe enough to affect activities over a period of at least 3
months. This definition had initially constituted the entry
criteria for their descriptive studies, but recurrent abdominal pain later became a term used clinically to describe all
children with abdominal pain without an organic etiology.
It is now agreed that recurrent abdominal pain is
a description rather than a diagnosis. Recurrent abdominal
pain, as a case definition, includes children with a variety
of functional gastrointestinal disorders causing abdominal
pain, such as nonulcer dyspepsia, IBS or abdominal
migraine. It may also include children with organic
disease. In this document, we will avoid use of the term
‘‘recurrent abdominal pain’’ whenever possible to lessen
the confusion that the term engenders. Table 1 summarizes
terms currently used to describe long-lasting constant or
intermittent childhood abdominal pain.
The preponderance of the available pediatric literature
on this subject is still based on the Apley and Naish
criteria (8). Thus, evidence was sought in articles that
were selected based on the presence of Apley and Naish
criteria as entry criteria unless the subcommittee felt that
other strong qualities (for example, large epidemiologic
study or double-blind randomized controlled trial [RCT])
justified their evaluation and inclusion as part of the
evidence. This meant that some articles including
children with abdominal pain of less than 3 months’
duration were excluded from consideration.
After a careful evaluation of the published literature,
no evidence-based procedural algorithm could be produced; instead, questions of interest to clinicians were
posed and clinical guidance was generated linked to the
standard clinical approach of history, physical examination,
diagnostic testing, and treatment. The document is
organized in the following manner: 1) the methodology
used to review the evidence and generate the statements
is described; 2) questions are answered regarding subgroups of disorders, the role of diagnostic evaluation
(history, laboratory tests, radiologic and invasive techniques and psychosocial evaluation) and the efficacy of
pharmacological, behavioral and surgical interventions;
and 3) a summary of the quality of the evidence is
provided (Appendix A).
METHODOLOGY
The guideline development process of Woolf et al. (9)
was used, with a subcommittee of experts and community physicians guiding the work of the methodologist
(HPL) to assemble the evidence, reviewing the results of
the methodologist, and using the Nominal Group
Technique (10) to arrive at conclusions based on the
evidence.
After initial discussions, 15 questions were defined
and collapsed into the eight questions in this review.
An initial search (Table 2) was performed on PubMed
(www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed) on
October 27, 2000, searching for ‘‘abdominal pain’’ in the
broadest possible way but limited to pediatric studies;
1498 titles were retrieved. This search was repeated on
June 19, 2002, providing another 158 references, for a
total of 1656.
In the review process, the following were exclusion
criteria: non-English, nonpediatric, nonrecurrent/nonfunctional/nonchronic abdominal pain, small study
(sample size #5), no original data, letters to the editor,
studies on Helicobacter pylori and study subjects not
baseline healthy (e.g., sickle cell disease patients). The
studies regarding H. pylori were excluded because the
literature regarding H. pylori had been reviewed recently
by a North American Society for Pediatric Gastroenterology, Hepatology and Nutrition committee and practice
guidelines had been published (11). All titles were
reviewed by a single reader (HPL); 10% of the excluded
articles were reviewed by two committee members
TABLE 1. Currently Used Definitions to Describe Childhood Abdominal Pain
Recurrent abdominal pain as defined
by Apley
RAP
Chronic abdominal pain
Rome II criteria for abdominal pain
Functional abdominal pain
Nonorganic abdominal pain
Psychogenic abdominal pain
3 or more episodes of abdominal pain, over a period of 3 or more mo, severe enough
to affect activities.
A common abbreviation for recurrent abdominal pain that has been used in the literature to depict
recurrent abdominal pain as defined by Apley. Many physicians incorrectly use this term to
imply functional abdominal pain.
Abdominal pain with a minimum duration of 3 mo. Some clinicians believe that pain that lasts
more than 1–2 mo is chronic.
Abdominal pain for at least 12 wk, which need not be consecutive, in the preceding 12 mo.
These criteria apply to IBS, functional dyspepsia, and functional abdominal pain.
Abdominal pain that occurs in the absence of anatomic abnormality, inflammation, or tissue damage.
A term that is often used interchangeably with functional abdominal pain.
A term that is often used interchangeably with functional abdominal pain.
IBS, irritable bowel Syndrome.
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
CHRONIC ABDOMINAL PAIN IN CHILDREN
TABLE 2. Literature Search Strategy
251
TABLE 3. Articles and Studies Processed in the Review
Search terms
Number of articles returned
Reason
Title
Abstract
Article
TOTAL
(((‘‘abdominal pain’’[MeSH
terms] OR abdominal pain [text
word]) AND notpubref[sb]) AND
‘‘child’’[MeSH Terms])
(((((chronic[all fields] OR
recurrent[all fields]) OR
functional [all fields]) AND
(‘‘abdominal pain’’[MeSH
terms] OR abdominal pain[text
word])) AND notpubref[sb])
AND ‘‘child’’[MeSH terms])
Clinical queries:
[1] AND therapy/sensitivity
[2] AND diagnosis/sensitivity
6662
Non-CAP
SS #5
Non-English
No original data
Nonpediatric
Nonbaseline
normal
Case series
Duplicates other
study
TOTAL*
Remaining articles
Methodology
reviewed
Article detailed
data review
Study detailed
review
688
143
164
35
32
16
114
32
16
51
86
5
55
33
69
20
1
857
208
180
155
138
22
62
60
2
242
2
1562*
94
94
1498
232
932
MeSH indicates medical subject heading (PubMed’s controlled
vocabulary); notpubref[sb] limits the search to the biomedical
literature.
(CDL, RBC), with 100% agreement regarding exclusion
criteria. Of nonrejected titles, abstracts were read by
a single reader (HPL) and further exclusions were made.
Articles were read by at least two readers (medical
student and HPL). Ten articles were abstracted in parallel, with similar results, demonstrating a reliable procedure. Data were abstracted regarding the study as
a whole, design and quality, patient groups and outcomes
and their values. Efforts were made to standardize the vocabulary used in recording the methodology and results,
resulting in a controlled vocabulary of 1262 terms. After
review, 94 articles were included in the evidence review.
The definitions of the study designs were as follows:
uncontrolled experiment—unspecified group of participants received intervention and follow-up data were
provided; case series cross section—data provided on a
single group of participants; case series follow-up—
baseline and follow-up data provided on a single group of
participants; cohort cross section—a single group of participants were divided into two or more groups on the basis of a specified feature (e.g., history or laboratory tests)
and described; cohort follow-up—baseline and follow-up
data provided on a single group of participants who were
divided into two or more groups; case-control—two or
more groups were assembled and retrospective or current
data are provided; and RCT—participants were randomly assigned to intervention and follow-up data are
provided. Because the questions were all comparative,
only studies with two arms or more were included in this
review (thereby excluding case series).
Table 3 shows the type of articles and studies as
processed in the review. Most articles were rejected on
the basis of title review. Some articles were rejected at
more than one point in the process, as indicated by the
overlaps. Ninety-four articles were left for review. Sixtyfour articles had full data investigation, which included
separating articles into one or more studies in case of,
1078
304
64
83
CAP, chronic abdominal pain; SS, sample size,
Non-CAP includes articles on Helicobacter and abdominal pain.
*These totals reflect the following overlaps: 45 rejected as abstracts
and titles, 9 articles rejected as abstracts and articles, 7 rejected as titles
and articles, 1 rejected as abstract, title, and article.
for example, a baseline case-control study with a cohort
follow-up; hence, the 64 articles translated into 83 studies.
An article might include more than one study if, for
instance, there was an initial cohort cross-section with
a subsequent cohort follow-up reported in the same
article. Of the 83 studies for which methodology was
reviewed, 46 were case-control, 20 were cohort cross
section, 10 were cohort follow-up and seven were RCTs.
A recent systematic review of treatments in recurrent
abdominal pain identified the same RCTs (12), providing
validation for our approach.
Data abstracted for each study as a whole included
study city, study country, single or multiple site, site type
(community, physician office, academic pediatric setting
or gastroenterologist office), funding source, age range,
mean and standard deviation, sample size, number of
groups, number of outcomes and number of time points.
A methodology review was performed for each study
on the basis of the Newcastle-Ottawa Scale for assessing
the quality of nonrandomized studies in meta-analyses
(13). Inclusion and exclusion criteria were noted using the
controlled vocabulary. The evidence was characterized in
terms of outcome type (based on the controlled vocabulary), outcome name (specific to this study), outcome units
(for continuous outcomes), outcome time point (baseline
or later), method (how outcome was assessed), sample size
at outset and sample size at termination (a difference from
sample size at outset indicated loss to follow-up). Data for
continuous outcomes (in which a quantity was measured
within a participant) were usually characterized by the
mean and standard deviation. For categorical data (in which
participants were counted once), the category was labeled
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
252
NASPGHAN
QUESTIONS
1. Is There Evidence that Children with Chronic
Abdominal Pain have Symptom Patterns that can
be Categorized as Functional Dyspepsia, IBS,
or Abdominal Migraine?
Fig 1. Geographic distribution of articles. Map courtesy http://
www.worldatlas.com.
using the controlled vocabulary, test statistic name, P value
(and comments) and data source (page/figure/table).
Figure 1 summarizes the geographic distribution of the
studies for which the country was provided. Of 89 articles
for which data were provided, 62 (70%) were performed
at a single site, 30 (34%) were based on research at an
academic pediatric center, 27 (31%) were performed at
a gastroenterology clinic, 17 (19%) were performed at the
community level and nine (10%) were performed at
general pediatric offices.
We calculated a quality score for each study as the
ratio of quality items attained to the total number of
items. The average, standard deviation and confidence
intervals are given for each design in Table 4. Although
the quality scores seem to increase for the more preferred
designs, the confidence intervals all overlap.
Evidence tables for each of the eight questions were
generated across studies and grouped according to arm
type, method, or outcome, as pertinent to the question. There
were 685 outcomes across the studies, categorized as
history outcomes (550, 80%), tissue/physiologic outcomes
(115, 17%), physical examination outcomes (15, 2%) and
use of medications (5, 1%). Among the 685 outcomes, 161
of the P values (23%) were not statistically significant,
and an additional 316 (46%) were not provided by investigators. Each subcommittee member took responsibility
for one or more questions. Each reviewed the evidence
tables and the primary articles and generated a summary of
the research. The scale for rating evidence is given in Table 5.
The reviews were discussed by the subcommittee, and
the Nominal Group Technique (10) was used to achieve
consensus.
TABLE 4. Quality Scores by Design
RCT
Cohort follow-up
Cohort cross section
Case-control
Number of
Studies
Average
Score (%)
SD
(%)
Confidence
Interval (%)
7
9
18
46
70
64
58
53
15
21
18
26
(58–82)
(50–78)
(50–67)
(45–60)
RCT, randomized controlled trials; SD, standard deviation.
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
There is limited but credible evidence of the existence
of functional dyspepsia, IBS and abdominal migraine in
children (evidence quality C).
Although often discussed as a homogeneous group of
patients, there are different phenotypic manifestations of
functional abdominal pain. The wide variety of descriptive terms applied to these patients’ symptoms, including irritable bowel of childhood, spastic colon of
childhood, nonorganic recurrent abdominal pain and
psychogenic recurrent abdominal pain, reflects both the
heterogeneity of the group and the limited understanding
of the pathogenesis of symptoms.
The sensitivity and specificity of the Apley and Naish
criteria have been questioned, and some investigators
have proposed the ‘‘Rome’’ criteria (14), which suggest
that many children and adolescents with recurrent or
chronic abdominal pain manifest symptom clusters that
facilitate the diagnosis of disorders on the basis of
symptoms alone. In 1999, a group of investigators (Rome
II committee) was charged with identifying and then
developing diagnostic criteria for childhood functional
disorders including recurrent abdominal pain. They
developed a symptom-based classification of functional
disorders associated with abdominal pain (Table 6). The
goal for these criteria was to decrease cost and suffering
for the patients by encouraging a defined-criteria diagnosis of the disorder rather than one obtained after
excluding organic diseases. The group felt that the classic
Apley and Naish criteria of recurrent abdominal pain
were too general and failed to recognize that recurrent
abdominal pain was not a final diagnosis. It was also
apparent to the group that children and adolescents often
displayed a symptom complex similar to previously
described functional disorders in adults, such as IBS and
functional dyspepsia. Clinical experience also suggested
that a symptom complex called abdominal migraine
existed.
A prospective study of 257 children 5 years or older
presenting with abdominal pain or discomfort, nausea or
vomiting for 1 month or more identified 127 subjects
meeting the Rome II criteria for dyspepsia (before
evaluation for disease) (15). Symptoms were ulcer-like
in 26% and dyspepsia-like in 15% of subjects. Fifty-six
of these subjects underwent esophagogastroduodenoscopy and 35 were found to have no evidence of disease.
These 35 subjects were believed to fulfill strict criteria
for functional dyspepsia. Symptoms of IBS were present
in approximately one fourth of patients with functional
dyspepsia.
CHRONIC ABDOMINAL PAIN IN CHILDREN
253
TABLE 5. Rating of Evidence Quality
Level
Criteria
A
Well-designed RCTs or diagnostic studies on relevant populations: 2 or more studies that compared the test with a criterion standard
in an independent, blind manner in an unselected population of children similar to those addressed in the report
RCTs or diagnostic studies with minor limitations and overwhelmingly consistent evidence from observational studies: a single study
that compared the test with a criterion standard in an independent, blind manner in an unselected population of children similar to
those addressed in the report.
Observational studies (case-control and cohort design)
Expert opinion, case reports, reasoning from first principles
B
C
D
Questionnaires administered during a populationbased study of middle school and high school students
revealed a symptom complex consistent with IBS in 6%
of middle-school students and 14% of high-school
students (2). None of these subjects were tested for
organic disease. A prospective study of 227 children
5 years or older referred to a pediatric gastroenterology
clinic for evaluation of chronic abdominal pain showed
that 117 had symptoms consistent with IBS (16).
Diagnostic testing failed to reveal underlying disease.
Concomitant upper abdominal discomfort or nausea was
present in one third of these subjects.
A well-designed and implemented epidemiologic
study (17) of a general population demonstrated an
increased prevalence of a lifetime maternal history of
migraine in children with recurrent abdominal pain,
migraine headache and abdominal migraine. Abdominal
migraine was defined as recurrent abdominal pain
associated with nausea or vomiting of sufficient severity
to stop normal activity plus three of the following: pallor,
fever, limb pain, dizziness or headache. Among study
patients, 2.4% had abdominal migraine. Children with
abdominal migraine were 2.6 times more likely to have
a maternal history of migraine. Another prospective
cross-sectional questionnaire study (18) of a large
random sample of school children 5 to 15 years old
compared children with migraine headaches and children
with abdominal migraine. Abdominal migraine was
TABLE 6. Rome II Criteria for Functional Bowel Disorders Associated With Abdominal Pain or Discomfort in Children
Functional dyspepsia: In children mature enough to provide an accurate pain history (at least 12 weeks, which need not be consecutive) within
the preceding 12 months of:
1. Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus); and
2. No evidence (including upper endoscopy) that organic disease is likely to explain the symptoms; and
3. No evidence that dyspepsia is exclusively relieved by defecation or associated with the onset of a change in stool frequency or stool form.
IBS: In children old enough to provide an accurate pain history (at least 12 weeks, which need not be consecutive) in the preceding 12 months of:
1. Abdominal discomfort or pain that has 2 of the following 3 features:
a. Relieved with defecation
b. Onset associated with a change in frequency of stool
c. Onset associated with a change in form (appearance) of stool
AND
2. There are no structural or metabolic abnormalities to explain the symptoms. The following symptoms also support a diagnosis of IBS:
a. Abnormal stool frequency defined as more than 3 bowel movements per day or fewer than 3 bowel movements per week
b. Abnormal stool form (lumpy/hard or loose/watery)
c. Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
d. Passage of mucus with stool
e. Bloating or feeling of abdominal distention
Functional abdominal pain: At least 12 weeks of:
1. Nearly continuous abdominal pain in a school-aged child or adolescent;
2. No, or only occasional, relation of pain with physiologic events (eg, eating, menses, or defecation);
3. Some loss of daily functioning;
4. Pain that is not feigned (eg, malingering); and
5. Insufficient criteria for other functional gastrointestinal disorders that would explain the abdominal pain
Abdominal migraine: In the preceding 12 months:
1. Three or more paroxysmal episodes of intense, acute midline, abdominal pain lasting 2 hours to several days, with intervening
symptom-free intervals lasting weeks to months;
2. Evidence of absence of metabolic, gastrointestinal, and central nervous system structural or biochemical diseases is absent; and
3. Two of the following features:
a. Headache during episodes
b. Photophobia during episodes
c. Family history of migraines
d. Headache confined to one side only
e. An aura or warning period consisting of visual disturbances, sensory symptoms, or motor abnormalities
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
254
NASPGHAN
defined as follows: 1) pain severe enough to interfere
with normal daily activities; 2) pain dull or colicky in
nature; 3) periumbilical or poorly localized pain; 4) any
two of anorexia, nausea, vomiting or pallor; 5) attacks
lasting for at least 1 hour; and 6) complete resolution of
symptoms between attacks. Approximately 4.1% had
abdominal migraine. Children with migraine headaches
were twice as likely to have abdominal migraine and
children with abdominal migraine were twice as likely to
have migraine headaches as the general population.
2. What is the Predictive Value of History Items?
There are no studies of unselected patients showing
that pain frequency, severity, location or effects on
lifestyle are able to distinguish between functional and
organic disorders (evidence quality C).
Children with recurrent abdominal pain are more likely
than children without recurrent abdominal pain to have
headache, joint pain, anorexia, vomiting, nausea, excessive gas and altered bowel symptoms. There are insufficient data to determine whether the presence of associated
symptoms can help the physician distinguish between
functional and organic disorders (evidence quality C).
The presence of alarm symptoms or signs suggests
a higher pretest probability or prevalence of organic
disease and may justify the performance of diagnostic
tests. Alarm symptoms or signs include, but are not
limited to, involuntary weight loss, deceleration of linear
growth, gastrointestinal blood loss, significant vomiting,
chronic severe diarrhea, persistent right upper or right
lower quadrant pain, unexplained fever and family history
of inflammatory bowel disease (evidence quality D).
Functional abdominal pain lacks a diagnostic marker.
Because no prospective studies on natural history or incidence compare the history of children with and without
recurrent episodes of abdominal pain, it cannot be stated
that duration of pain itself supports a diagnosis of functional pain. The committee was able to identify 25 peerreviewed studies of patients with chronic abdominal pain
of greater than 3 months’ duration in which symptom
description was included in the results and patient
selection criteria were most likely to exclude author bias
(survey, questionnaire or consecutive patients prospectively or retrospectively enrolled for study) (2,8,19–41).
One quarter of these studies were performed in North
America, one quarter were performed in the Far East and
half were performed in Europe. The available studies
provide evidence that frequency, severity, location and
timing (postprandial, waking during night) of abdominal
pain do not help distinguish between organic and functional abdominal pain. Children with recurrent episodes
of abdominal pain are more likely than children without
abdominal pain or children with behavior disorders to
have anorexia, nausea, episodic vomiting, constipation,
diarrhea, headache, arthralgia or eye problems. Yet none
of these associated symptoms have been reported to help
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
distinguish between organic and functional abdominal
pain. Younger age of onset of pain and inability to attend
school because of pain were associated with a decision to
consult a physician (37).
Physical examination of children with recurrent or
chronic abdominal pain has rarely been described. The
presence of tenderness on abdominal palpation has been
reported to be characteristic of children with recurrent
episodes of abdominal pain without evidence of organic
disease when compared with control children (28).
3. What is the Predictive Value of Laboratory Tests?
There is no evidence to evaluate the predictive value of
blood tests (evidence quality D).
There is no evidence to determine the predictive value
of blood tests in the face of alarm signals (evidence
quality D).
Because researchers have used results of laboratory
testing as inclusion or exclusion criteria for functional
abdominal pain, there are no studies that have evaluated
the usefulness of common laboratory tests (complete
blood cell count, erythrocyte sedimentation rate, comprehensive metabolic panel, urinalysis, stool parasite analysis) to distinguish between organic and functional
abdominal pain. Investigations of specific biologic
markers have described significant differences between
patients with recurrent episodes of abdominal pain and
control subjects (such as increased plasma cholecystokinin concentrations and decreased plasma oxytocin and
cortisol concentrations in children with pain) (29,42).
However, the number of patients in these studies is small
and the value of such measurements to clinical practice
remains to be determined. The coexistence of abdominal
pain and an abnormal test result for a common gastrointestinal disorder, such as lactose malabsorption or
H. pylori infection, does not necessarily indicate a causal
relationship between the two. Treatment of lactose
malabsorption often does not result in resolution of
abdominal pain, and children with H. pylori infection
are not more likely to have abdominal pain than children
without H. pylori. Children with lactose malabsorption
may have a phenotype overlapping with diarrheapredominant IBS.
4. What are the Predictive Values of Other
Diagnostic Tests?
There is no evidence to suggest that the use of
ultrasonographic examination of the abdomen and pelvis
in the absence of alarm symptoms has a significant yield
of organic disease (evidence quality C).
There is little evidence to suggest that the use of
endoscopy and biopsy in the absence of alarm symptoms
has a significant yield of organic disease (evidence
quality C).
CHRONIC ABDOMINAL PAIN IN CHILDREN
There is insufficient evidence to suggest that the use of
esophageal pH monitoring in the absence of alarm
symptoms has a significant yield of organic disease
(evidence quality C).
Ultrasonographic examination of the abdomen and
pelvis is a painless, noninvasive and inexpensive test that
can detect abnormalities of the kidneys, gallbladder,
liver, pancreas, appendix, intestines, ovaries and uterus.
When abdominal and pelvic ultrasonography has been
performed in children with recurrent episodes of
abdominal pain without alarm symptoms, abnormalities
have been found in fewer than 1% (43). Abnormalities
detected on ultrasonography may not be causally related
to the patient’s abdominal pain. When atypical symptoms
are present, such as jaundice, urinary symptoms, back or
flank pain, vomiting or abnormal findings on physical
examination, an abdominal and pelvic ultrasonography
is more likely to detect an abnormality (approximately
10%).
Endoscopy and biopsy of the esophagus, stomach and
duodenum, an invasive and expensive procedure, can
detect esophagitis, gastritis, duodenitis and ulceration.
Esophageal pH monitoring, also an invasive and expensive test, measures the frequency and duration of exposure of the esophagus to gastric acid as a means of
diagnosing gastroesophageal reflux. Studies of endoscopy, biopsy or esophageal pH monitoring performed in
children with recurrent abdominal pain have demonstrated abnormalities in 25% to 56%, but reports have been
limited by small sample size, sample bias, variability
of findings and questionable specificity and generalizability (40,44–46). Endoscopic or histopathologic abnormalities, such as esophagitis, gastritis or duodenitis, do
not predict the prognosis, which is generally favorable
in children with recurrent abdominal pain, including
dyspepsia (15).
255
stress influences symptom severity, course or response to
treatment (evidence quality D).
Studies including comparison groups of other patients
are relevant in assessing the value of the psychosocial
history in the differential diagnosis of chronic abdominal pain. One study (47) compared 30 pediatric patients
with recurrent episodes of abdominal pain with 30 patients referred for acute minor illness or injury. Life event
change in the previous year did not differ significantly
between the two groups. Another study found no difference between patients with recurrent abdominal pain
and patients with minor organic disease (e.g., gastritis,
esophagitis) on measures of patients’ personal life events
or mothers’ reports of family life events (48). No studies
have found that the presence of life event stress significantly differentiates patients with functional abdominal pain from other patient groups.
Nonetheless, several investigations have reported
higher levels of life stress in children with chronic abdominal pain compared with children without abdominal
pain. Two studies compared pediatric patients with abdominal pain with healthy school children and found
significantly higher levels of life event stress in patients
with pain (23,49). A diary study found that patients with
recurrent episodes of abdominal pain reported significantly more daily stressors than healthy school children,
and moreover, the relation between daily stressors and
somatic complaints was significantly stronger for patients
with abdominal pain than for healthy school children
(41). Thus, although there is no evidence that life stress
helps distinguish between patients with functional abdominal pain and patients with organic disease, children
with functional abdominal pain may experience stressors
that warrant attention. Additional research is needed to
evaluate whether these stressors contribute to symptom
severity, course or response to treatment.
Emotional/Behavioral Symptoms
5. What is the Diagnostic Value of the
Psychosocial History?
The literature was reviewed with respect to three
domains of psychosocial history: life event stress, child
emotional/behavioral symptoms and family functioning.
Life Event Stress
There is a small amount of evidence suggesting that
the presence of recent negative life events is not useful in
distinguishing between functional abdominal pain and
abdominal pain of other causes (evidence quality B).
There is limited evidence suggesting that daily stressors
are associated with the occurrence of pain episodes and
that higher levels of negative life events are associated
with increased likelihood of symptom persistence (evidence quality C). There is no evidence on whether life
There is evidence suggesting that the presence of
anxiety, depression or behavior problems is not useful in
distinguishing between functional abdominal pain and
abdominal pain of other causes (evidence quality B).
There is evidence that patients with recurrent abdominal
pain have more symptoms of anxiety and depression (internalizing emotional symptoms) than do healthy community controls (evidence quality B). In contrast, there is
evidence that children with recurrent abdominal pain do
not have higher levels of conduct disorder and oppositional behavior (externalizing emotional symptoms)
compared with healthy community controls (evidence
quality B). There are no data on whether emotional/behavioral symptoms predict symptom severity, course or
response to treatment (evidence quality D). There is
evidence suggesting that children with recurrent abdominal pain are at risk of later emotional symptoms and
psychiatric disorders (evidence quality B).
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
256
NASPGHAN
Several studies have used standardized measures to
assess emotional/behavioral symptoms in patients with
chronic abdominal pain and other patient groups. In
a study comparing 30 patients with abdominal pain with
30 patients with acute minor illness or injury, no
significant differences were found between the patient
groups when depression was assessed by interview or by
a child self-report measure (47). Another study comparing 19 patients with functional abdominal pain with 19
patients with an organic etiology of abdominal pain
found no significant differences between the groups on
the Child Behavior Checklist completed by the mother or
on the Rutter B2 Behavioural Scale completed by the
teacher (50). Similarly, no significant differences were
found between patients with and without organic findings
in two studies that included pediatric patients whose
abdominal pain ranged in duration from 1 month to
several years (48,51). Thus, no studies have found
a significant difference between patients with abdominal
pain that is functional or organic in etiology with respect
to emotional/behavioral symptoms.
Considerable evidence suggests that patients with
chronic abdominal pain have more symptoms of anxiety
and depression than do community controls. In a study of
31 children with recurrent abdominal pain and 31
matched classroom control children, mothers’ reports
indicated significantly higher scores for internalizing
emotional symptoms (anxiety, depression) in children
with abdominal pain (52). Teachers’ reports did not show
significant group differences. However, a structured
diagnostic interview indicated that 26 of the 31 children
with abdominal pain met the criteria for a psychiatric
diagnosis. In most cases, these diagnoses were anxiety
related. Others also have observed higher levels of
anxiety and depression in patients with recurrent
episodes of abdominal pain compared with community
controls (48,51), although one study found that patients
with abdominal pain were within the normal range for
anxiety and depression on the basis of published
normative data (53), and another found no difference
between patients with abdominal pain and controls on
self-report or interview measures of depression (25). A
community-based study of students in middle and high
school found that those with IBS-like symptoms had
significantly higher scores than their peers without IBS
on self-report questionnaire measures of anxiety and
depression (2). In contrast to the positive findings for
anxiety and depression, no studies have found significant
differences between children with recurrent episodes of
abdominal pain and community controls on measures of
conduct disorder or oppositional behavior.
Finally, results of three studies suggest that children
with recurrent abdominal pain may be at risk of later
anxiety and depression. A recent study compared 28
young adults evaluated for functional abdominal pain
between the ages of 6 and 17 years with 28 matched
former childhood participants of a study of tonsillectomy
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
and adenoidectomy (controls) (7). An average of 11 years
after the target visit, a structured psychiatric diagnostic
interview was administered to identify psychiatric disorders based on Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) (54) criteria.
Compared with controls, those with persistent abdominal
pain were significantly more likely to meet criteria for
a lifetime or current history of anxiety disorder. In
another study, children with abdominal pain and controls
were identified in data from a national longitudinal birth
cohort study (34). At 36 years of age, participants were
administered a semistructured psychiatric interview that
generated scores representing thresholds for psychiatric
disorder. Persistent abdominal pain in childhood was
significantly associated with psychiatric disorder in
adulthood. In a prospective study of 31 patients with recurrent abdominal pain and 31 control children, mothers’
reports of depressive symptoms and anxiety in their
children 5 years after baseline assessment were significantly higher for abdominal pain patients than for control
children (55).
Family Functioning
There is evidence that parents of patients with
recurrent abdominal pain have more symptoms of
anxiety, depression and somatization than do parents of
community controls or parents of other pediatric patients
(evidence quality C). There is some evidence that families
of patients with recurrent abdominal pain do not differ
from families of control children or families of patients
with acute illness in broad areas of family functioning,
such as family cohesion, conflict and marital satisfaction
(evidence quality C).
Two studies have used structured diagnostic interviews
to assess family history of psychiatric disorders in
patients with recurrent episodes of abdominal pain
compared with other patient groups. In one study, 28
adults with a childhood history of recurrent episodes of
abdominal pain were compared with 28 adults who had
undergone minor surgery as children (controls) (7).
Participants with a history of childhood abdominal pain
were significantly more likely than controls to report
having a first-degree relative with generalized anxiety
disorder, and there was a trend suggesting group differences on family history of major depression. In another
study, on the basis of interviews with 20 mothers of
children with functional abdominal pain and 20 mothers
of children with an organic etiology for abdominal pain,
the mean number of psychiatric disorders per relative
was found to be significantly higher in the functional pain
group than in the organic pain group (56). With respect to
particular types of disorders, a significant difference was
found only for somatization disorder, with the functional
group having a higher proportion of affected relatives. A
third study (51) found that compared with control
parents, mothers (but not fathers) of children with
CHRONIC ABDOMINAL PAIN IN CHILDREN
recurrent episodes of abdominal pain had significantly
higher levels of anxiety, depression and somatization
symptoms. Studies also have reported higher levels of
emotional distress in parents of children with recurrent
episodes of abdominal pain compared with parents of
children without abdominal pain (24,25,34).
Finally, a few studies have examined broad areas of
family functioning. These studies have found no difference between patients with abdominal pain and other
patient groups or controls on measures of parent marital
satisfaction (47,48) or family cohesion and conflict (48).
In one study, children with recurrent episodes of abdominal pain reported greater parental encouragement of
illness behavior than did children without abdominal
pain (48).
6. What is the Effectiveness of
Pharmacologic Treatment?
A thorough review of the literature with a focus on
RCTs revealed a paucity of studies examining pharmacologic and dietary interventions. Therefore, definitive
statements concerning therapeutic efficacy are quite
limited.
There is evidence that treatment for 2 weeks with
peppermint oil may provide benefit in children with IBS
(evidence quality B).
In a randomized, double-blind, controlled trial, 42
children with IBS were given pH-dependent, entericcoated peppermint oil capsules or placebo. After 2 weeks,
75% of those receiving peppermint oil had decreased
severity of pain associated with IBS (57). It was concluded that peppermint oil can be used as a therapeutic
agent during the symptomatic phase of IBS. This was
a short study of an agent not commonly used in the
treatment of IBS. Entry criteria were not well described,
other symptoms were not affected, and the safety and
palatability of the drug were not described. Despite these
shortcomings, the study represents an important proofof-concept study supporting a beneficial effect of a medication with possible smooth muscle-relaxing properties
in children with IBS.
There is inconclusive evidence of the benefit of H2receptor antagonists to treat children with dyspepsia
(evidence quality B).
A double-blind, placebo-controlled trial of famotidine
was conducted in 25 children with abdominal pain and
dyspepsia (58). Among the different variables evaluated,
only the global evaluation suggested that there was
a benefit of famotidine over placebo. Using the quantitative assessment, however, the mean improvement of
the score using famotidine versus placebo was not
statistically significant. There was also a significant improvement in symptoms during the first treatment period
regardless of the medication used. A subset of patients
with dyspeptic symptoms demonstrated a significant
257
benefit from the drug. In this study, enrolled children had
to meet Apley and Naish criteria and had to have
dyspeptic symptoms. The study population was heterogeneous, with some patients having positive H. pylori
titers and others having an abnormal lactose breath
hydrogen test. It is the opinion of the subcommittee that
H2-receptor antagonists may be beneficial for children
with severe dyspeptic symptoms (including heartburn),
but the results were difficult to generalize to children
with functional abdominal pain.
There is inconclusive evidence that fiber supplement intake decreases the frequency of pain attacks
for patients with recurrent abdominal pain (evidence
quality B).
A randomized, double-blind, placebo-controlled study
in 52 children with recurrent episodes of abdominal
pain recruited from primary care practices (59) demonstrated a statistically significant decrease in pain attacks
in children who were given additional fiber, compared
with those receiving placebo. The study involved small
groups (26 each), and improvement was marginal (seven
improved with placebo and 13 with fibers).
There is inconclusive evidence that a lactose-free diet
decreases symptoms in children with recurrent abdominal pain (evidence quality B).
In a study of 103 children 6 to 14 years of age with
nonlocalized abdominal pain for 4 months, a similar
prevalence of lactase deficiency was found in the control and abdominal pain groups (60). Thirty-eight patients completed three successive 6-week diet trials
conducted in a double-blind fashion. The patients were
then placed on a 12-month milk elimination diet. The
results suggested that the elimination of lactose did
not affect the overall rate of improvement in abdominal
pain. In addition, the recovery rate was similar in both
lactose absorbers and nonabsorbers, independent of
dietary restrictions. This study suggested that lactose
intolerance and recurrent abdominal pain are two separate entities, and a lactose-free diet has no effect on
outcome of abdominal pain in lactose absorbers and
nonabsorbers.
There are limited data to suggest that pizotifen is
efficacious in the treatment of abdominal migraine
(evidence quality B).
Pizotifen is a potent antagonist of the 5-HT2A receptor
that is not approved for use in the United States. A
placebo-controlled crossover study used pizotifen for the
treatment of 14 children with abdominal migraine (61).
Patients received either pizotifen (0.25 mg, twice daily)
or placebo syrup for 2 months, then the alternate treatment for 2 months. While being treated with pizotifen,
the study children had fewer days of abdominal pain and
lower indices of severity and misery. The medication was
well tolerated. These results may not be generalizable to
children with milder symptoms. Common adverse effects
include drowsiness, dizziness, increased appetite and
weight gain.
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
258
NASPGHAN
7. What is the Effectiveness of
Cognitive-Behavioral Therapy?
There is evidence that cognitive-behavioral therapy
may be useful in improving pain and disability outcome
in the short term (evidence quality B).
Two RCTs (62,63) evaluated the efficacy of a cognitivebehavioral program and a cognitive-behavioral family
intervention for the treatment of nonspecific abdominal
pain. In the first study, results showed that both the experimental and the control groups had decreased levels of
pain. However, the treated group improved more quickly,
the effects generalized to the school setting, and a larger
proportion of subjects were completely pain-free by 3-month
follow-up. In the second study, the children and mothers
who were taught coping skills had a higher rate of complete elimination of pain, lower levels of relapse at 6 and
12 months’ follow-up and lower levels of interference
with their activities as a result of pain, and parents reported a higher level of satisfaction with the treatment.
After controlling for pretreatment levels of pain, children’s
active self-coping and mothers’ caregiving strategies
were significant independent predictors of pain behavior
after treatment.
8. What is the Effectiveness of Surgery?
There is no evidence of the possible beneficial role of
surgery in the evaluation or management of children with
recurrent abdominal pain (evidence quality D).
There are no studies comparing diagnostic or therapeutic surgery with other approaches (evidence quality D).
The literature search identified a study (64) aimed at
evaluating the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain. It was
a series of 13 children with chronic severe episodes of
abdominal pain who were subjected to diagnostic laparoscopy. Extensive laboratory and imaging studies did
not contribute to the diagnosis. Laparoscopic findings
that identified the cause of abdominal pain were obtained
in 12 of 13 patients. Laparoscopic appendectomy was
performed in all patients. Follow-up varied from 6 months
to 3 years. Abdominal pain resolved in 10 patients. It was
concluded that diagnostic laparoscopy is a valuable
procedure in the management of children with chronic
recurrent abdominal pain. The study patients represented
a subgroup of children with very severe symptoms of
abdominal pain, all having required hospitalization and
multiple imaging studies. Although they were all found
to have an organic etiology for their pain, some of the
etiologies may actually be debatable as causes of disease—for example, cecal adhesion or fibrosed appendix. Two
patients required another laparoscopy for complications
related to the first one. No other study addresses laparoscopy or other procedures as treatments of recurrent
abdominal pain.
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005
SUMMARY
Chronic abdominal pain (long-standing intermittent or
constant abdominal pain) is common in children and
adolescents. In most children, chronic abdominal pain is
functional—that is, without objective evidence of an
underlying organic disorder. Yet an important part of the
physician’s job is to determine which children have an
organic disorder. A review of the current evidence,
however, indicates that there are no studies showing that
pain frequency, severity, location or effects on lifestyle
help to discriminate between functional and organic
disorders. Children with chronic abdominal pain are more
likely than children without chronic abdominal pain to
have headache, joint pain, anorexia, vomiting, nausea,
excessive gas and altered bowel symptoms, but there is
insufficient evidence that the presence of the associated
symptoms can help the physician discriminate between
functional and organic disorders. Although children with
chronic abdominal pain and their parents are more often
anxious or depressed, the presence of anxiety, depression,
behavior problems or recent negative life events does not
appear to be useful in distinguishing between functional
and organic abdominal pain.
There is evidence that children with functional abdominal pain can have symptom clusters characterized as functional dyspepsia, IBS or abdominal migraine as well as
isolated abdominal pain. Some patients have features of
more than one type of functional abdominal pain.
The physician must also decide whether to order diagnostic tests and, if so, which tests. The presence of alarm
symptoms or signs suggests a higher pretest probability
or prevalence of organic disease and may justify the
performance of diagnostic tests. Alarm symptoms or
signs include, but are not limited to, weight loss, deceleration of linear growth velocity, significant vomiting,
chronic severe diarrhea, evidence of gastrointestinal
blood loss, persistent right upper or right lower quadrant
pain, unexplained fever, family history of inflammatory
bowel disease or abnormal or unexplained physical
findings. The predictive value of blood tests, with or
without alarm signals, has not been adequately studied.
There is no evidence to suggest that the use of ultrasonographic examination of the abdomen and pelvis in the
absence of alarm symptoms has a significant yield of
organic disease. There is little evidence to suggest that
the use of endoscopy with biopsy or esophageal pH
monitoring has a significant yield of organic disease in
the absence of alarm symptoms.
There is limited evidence suggesting that daily
stressors are associated with the occurrence of pain
episodes and that higher levels of negative life events are
associated with increased likelihood of symptom persistence. Some evidence suggests that patients with chronic
abdominal pain have more symptoms of anxiety and
depression than do community controls and are at greater
risk of later emotional symptoms and psychiatric
CHRONIC ABDOMINAL PAIN IN CHILDREN
disorders. However, there are no data on whether emotional or behavioral symptoms predict symptom severity,
course or response to treatment. Parents of patients with
chronic abdominal pain appear to have more symptoms
of anxiety, depression and somatization than do parents
of community controls or parents of other pediatric
patients. However, families of children with chronic
abdominal pain do not appear to differ from families of
children without abdominal pain or families of patients
with acute illness in broad areas of family functioning.
There have been few studies of the treatment of
chronic abdominal pain in children. There is inconclusive
evidence that a lactose-free diet decreases symptoms or
that a fiber supplement decreases the frequency of pain
attacks. There is inconclusive evidence of the benefit of
acid suppression with H2-receptor antagonists to treat
children with dyspepsia. There is evidence that treatment
for 2 weeks with peppermint oil may provide benefit in
children with IBS. There is also evidence that cognitive/behavioral therapy may be useful in improving pain
and disability outcome in the short term.
AUTHORS:
Carlo Di Lorenzo, M.D.
Columbus, OH
Richard B. Colletti, M.D.
Burlington, VT
Horald P. Lehmann, M.D., Ph.D.
Baltimore, M.D.
John T. Boyle, M.D.
South Birmingham, A.L.
William T. Gerson, M.D.
Burlington, VT
Jeffrey S. Hyams, M.D.
Hartford, CT
Robert H. Squires, Jr., M.D.
Dallas, TX
Lynn S. Walker, Ph.D.
Nashville, TN
STAFF:
Pamela T. Kanda, M.P.H.
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TABLE 1. APPENDIX A. Summary of the Quality of the Evidence
Question
Evidence
Quality of Evidence
1
There is limited but credible evidence of the existence of functional dyspepsia, IBS, and abdominal
migraine in children.
There are no studies of unselected patients showing that pain frequency, severity, location, or effects
on lifestyle are able to distinguish between functional and organic disorders.
Children with recurrent abdominal pain are more likely than children without recurrent abdominal pain to
have headache, joint pain, anorexia, vomiting, nausea, excessive gas, and altered bowel symptoms.
There are insufficient data to determine whether the presence of associated symptoms can help
the physician to distinguish between functional and organic disorders.
The presence of alarm symptoms or signs suggests a higher pretest probability or prevalence of organic
disease and may justify the performance of diagnostic tests. Alarm symptoms or signs include but are not
limited to involuntary weight loss, deceleration of linear growth, gastrointestinal blood loss, significant
vomiting, chronic severe diarrhea, persistent right upper or right lower quadrant pain, unexplained fever,
and family history of inflammatory bowel disease.
There is no evidence to evaluate the predictive value of blood tests.
There is no evidence to determine the predictive value of blood tests in the face of alarm signals.
There is no evidence to suggest that the use of ultrasonographic examination of the abdomen and pelvis
in the absence of alarm symptoms has a significant yield of organic disease.
There is little evidence to suggest that the use of endscopy and biopsy in the absence of alarm symptoms
has a significant yield of organic disease.
There is insufficient evidence to suggest than the use of esophageal pH monitoring in the absence of alarm
symptoms has a significant yield of organic disease.
There is a small amount of evidence suggesting that the presence of recent negative life events is not useful
in distinguishing between functional abdominal pain and abdominal pain of other causes.
There is limited evidence suggesting that daily stressors are associated with the occurrence of pain episodes
and that higher levels of negative life events are associated with increased likelihood of symptom persistence.
There is no evidence on whether life stress influences symptom severity, course, or response to treatment.
There is evidence suggesting that the presence of anxiety, depression, or behavior problems is not useful in
distinguishing between functional abdominal pain and abdominal pain of other causes.
There is evidence that patients with recurrent abdominal pain have more symptoms of anxiety and depression
(internalizing emotional symptoms) than to healthy community controls.
In contrast, there is evidence that children with recurrent abdominal pain do not have higher levels of conduct
disorder and oppositional behavior (externalizing emotional symptoms) compared with healthy
community controls.
There are no data on whether emotional/behavioral symptoms predict symptom severity, course, or response
to treatment.
There is evidence suggesting that children with recurrent abdominal pain are at risk of later emotional
symptoms and psychiatric disorders.
There is evidence that parents of patients with recurrent abdominal pain have more symptoms of anxiety,
depression, and somatization than do parents of community controls or parents of other pediatric patients.
There is some evidence that families of patients with recurrent abdominal pain do not differ from families of
community controls or families of patients with acute illness in broad areas of family functioning,
such as family cohesion, conflict, and martial satisfaction.
There is evidence that treatment for 2 weeks with peppermint oil may provide benefit in children IBS.
There is inconclusive evidence of the benefit H2-blockers to treat children with dyspepsia.
There is inconclusive evidence that fiber supplement intake decreases the frequency of pain attacks for patients
with recurrent abdominal pain.
There is inconclusive evidence that a lactose-free diet decreases symptoms in children with recurrent
abdominal pain.
There are limited data to suggest that pizotifen is efficacious in the treatment of abdominal migraine.
There is evidence that cognitive-behavioral therapy may be useful in improving pain and disability
outcome in the short-term.
There is no evidence of the possible beneficial role of surgery in the evaluation or management of children with
recurrent abdominal pain.
There are no studies comparing diagnostic or therapeutic surgery with other approaches.
C
2
2
2
3
3
4
4
4
5
5
5
5
5
5
5
5
5
5
6
6
6
6
6
7
8
8
C
C
D
D
D
C
C
C
B
C
D
B
B
B
D
B
C
C
B
B
B
B
B
B
D
D
J Pediatr Gastroenterol Nutr, Vol. 40, No. 3, March 2005